Provider Demographics
NPI:1093856163
Name:JEFFERSON COUNTY HEALTH DEPARTMET
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HEALTH DEPARTMET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL PROGRAM COORDINATOER
Authorized Official - Prefix:
Authorized Official - First Name:RYANN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SUMMERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:636-282-1010
Mailing Address - Street 1:1818 LONEDELL RD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-1050
Mailing Address - Country:US
Mailing Address - Phone:636-282-1010
Mailing Address - Fax:636-282-2525
Practice Address - Street 1:1818 LONEDELL RD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-1050
Practice Address - Country:US
Practice Address - Phone:636-282-1010
Practice Address - Fax:636-282-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO16116011251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO002932OtherHYGIENIST STATE LICENCE